CANCER OF THE HYPOPHARYNX 237

metastatic gland. One helpful guide is that metastatic glands do not move on
swallowing.

Radiology. This is a mandatory investigation in all patients complaining of
any throat symptoms. The plain radiograph is of limited value but an en-
largement of the soft-tissue shadow posterior to the trachea is suggestive of a
postcricoid tumour. As a general rule if the soft-tissue shadow is wider than
the body of a vertebra then it is abnormal. Tumours of the pyriform fossa may
also destroy areas of the thyroid cartilage.

The key investigation is the barium swallow which should demonstrate
95 per cent of all hypopharyngeal tumours. The greatest use of this investiga-
tion is in delineating the lower end of a cervical oesophageal lesion through
which an oesophagoscope cannot be passed. A chest radiograph will
occasionally show multiple opacities which may be secondary deposits or
patches of consolidation due to aspiration of food.

Endoscopy. This will be done in every patient with an abnormal barium
radiograph and also in those who have experienced food sticking or a feeling
of a 'crumb* in the throat. The short oesophagoscope, the laryngoscope and
the female small-diameter oesophagoscope are the most commonly used
instruments. Not only must a biopsy be done but an accurate assessment
of the extent of the tumour must be made because this will influence
treatment.

TREATMENT POLICY. At the outset it should be said that the 5-year survival
for any of these tumours is poor. Many of the patients present late with
advanced tumours, and because of age, tumour dissemination and general
condition about 1 in 3 are not treated by any modality. There is no such
thing as 'palliative* radiotherapy in these tumours; they seldom have pain and
radiotherapy will cause painful mucositis. Of those untreated, death will be by
aspiration pneumonia in most instances. If the growth has been considered
too advanced for successful treatment the general practitioner should be so
informed, and he should not seek to prolong life by antibiotic therapy for
intercurrent infections.

In nearly all cases it will be necessary to remove the larynx as well as the
pharynx if surgery is chosen as the primary modality. On the other hand,
radiotherapy does not show encouraging results, the best being about a
20 per cent 5-year survival. Another fact that must be borne in mind is the
high incidence of lymphatic metastases.

Pyriform Fossa. If the tumour is small and does not involve the postcricoid
region a total laryngectomy and partial pharyngectomy can be done, closing
the remaining pharynx primarily. If a gland is palpable, and even if none is
palpable, a radical neck dissection should be done.

If the tumour involves the postcricoid region or cervical oesophagus a total
laryngopharyngectomy with radical neck dissection will be required. The
pharynx is rebuilt by using deltopectoral skin flaps.

Postcricoid. In this site the cervical oesophagus will be involved and because
clearance will require to be at least a hand's breadth, due to 'skip* lesions,
repair with skin flaps is impractical. Because fresh tissue will be brought in for
the repair and as lymph node metastases are less common, radiotherapy is the
best initial treatment. If it is successful, the patient will keep his larynx. If it
fails, a total laryngopharyngo-oesophagectomy will need to be done using
either stomach or colon to replace the pharyngo-oesophagus. It is the author's